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Voters' views on the economy will probably determine the outcome of the 2012 presidential election, but the electorate should really be focusing on health care. The ability of presidents to change the course of our $15 trillion national economy, at least in the short term, is debatable at best. After all, how much control does the President have over the Eurozone recession, the slowing economies of China and India, the price of oil and gas, or the technological changes that are forcing less-educated workers out of manufacturing jobs?

But the next President will profoundly influence the future of our health care system. Not since the 1964 contest between Barry Goldwater and Lyndon Johnson, whose victory made possible the enactment of Medicare and Medicaid, has a presidential contest carried such significant, immediate, and certain implications for physicians, patients, and all the other stakeholders in our health care system.

The first thing to note, of course, is that President Obama and Governor Mitt Romney have profound differences in their health policies. President Obama's views on health care are familiar. As the Patient Protection and Affordable Care Act (ACA) demonstrates, he clearly believes in the value and necessity of federal leadership to assure coverage for the uninsured, to eliminate private insurance practices that discriminate against sick individuals, and to reform the health care delivery system.

Judging by his campaign Web site (1), Governor Romney takes a very different view. He supports the repeal of the ACA and will begin working to achieve this on his first day in office by issuing “an executive order that paves the way for the federal government to issue Obamacare waivers to all fifty states.” His own plan for addressing the health care system's problems emphasizes state flexibility and leadership, increased market competition, and greater consumer choice. The underlying philosophy seems to be opposition to federal solutions; belief in state rights; and faith in free markets to address problems of cost, access, and quality in our health care system. Congressman Paul Ryan's proposed reliance on premium support—“vouchers”—to fund the Medicare program is consistent with this market-oriented approach to health care problems. The Governor advances no ideas, at least on his Web site, for covering the nation's uninsured (1).

Republicans and Democrats usually differ in their health care policies, but these differences carry much more profound implications in 2012 than they have in the past. The reason is that the next President will decide how and whether to continue implementing the ACA, which is arguably the most sweeping health care legislation ever enacted in the United States. The reelection of President Obama will assure that the executive branch of the federal government will implement the ACA as vigorously as possible and that even a hostile Congress will be unable to repeal or defund it, given the difficulty of overcoming a presidential veto.

In contrast, the election of Governor Romney could lead to repeal and/or defunding of important elements of the ACA, especially if Republicans control both houses of the Congress, which is possible. Even if Republicans do not control the federal legislature, a future President Romney could profoundly redirect, slow, or stop altogether the implementation of major elements of the ACA. For example, the President has considerable discretion in how vigorously to use the federal government's authority under the ACA to set up health insurance exchanges in states that don't choose to do so themselves and in how to use ACA authorities to regulate private insurance practices that could discriminate against sick and high-cost patients. Given the Governor's announced support for state flexibility and discretion, he seems unlikely to encroach aggressively on the states' freedom to manage their own health insurance markets. The likely result is that many fewer Americans may have the ability to purchase private insurance through state health insurance exchanges under a Romney administration than under President Obama. A Romney administration is also likely to impose fewer constraints on the sale and pricing of private insurance plans, such as federal regulations preventing insurers from discriminating against sick and costly patients.

To be more concrete concerning the possible effects of the 2012 presidential election on patients, physicians, and hospitals, let's run through 1 specific and not-improbable scenario. President Mitt Romney takes office in January 2013 with a narrow Republican majority in the Senate and a smaller but still secure Republican majority in the House. Using the process known as “budget reconciliation,” which exempts certain budget proposals from Senate filibuster, the Senate and House pass a new federal budget that strips out funding for the ACA to expand the Medicaid program and to subsidize coverage for low-income Americans. The President signs the bill into law, thus blocking the implementation of ACA provisions that would have covered approximately 32 million uninsured citizens.

Cognizant of the problem of uninsurance, President Romney proposes to continue requiring insurance companies to cover children on their parents' policies until age 26, and given the popularity of this ACA provision, Republicans acquiesce. Romney also proposes a more comprehensive policy typically supported by Republicans. He would end or reduce the preferential tax treatment of health insurance premiums paid by employers in the workplace and devote the resulting federal revenues to tax credits offered individuals who wish to purchase private health plans in the open market (2). However, Democrats ferociously oppose this plan—which is anathema to unions and to some employers—and even some Republicans get cold feet in the face of the resulting controversy, concluding that the repeal of major ACA elements is sufficient to honor campaign pledges. A frustrated President Romney declares victory and moves on to other priorities while blaming Democrats for not covering the uninsured.

The net result is that, with the exception of privately insured children, the nation returns to the situation that existed in 2008, when the ranks of uninsured Americans were growing by about 1 million a year as employers steadily dropped coverage (3). By 2020, the number of uninsured approaches 60 million or 20% of the population, and the quality of private insurance continues to decline as employers reduce the generosity of coverage to manage increasing premiums. Physicians find their revenues jeopardized and their care plans frustrated as more and more of their patients lack the ability to pay for prescribed care. Hospitals find that their uncompensated care burdens grow considerably larger because of reduced Medicaid payments and increased numbers of uninsured patients.

All this, of course, is speculation. Governor Romney's views on health care could evolve, as could President Obama's if he is reelected. But based on what we know now, 2012 will be the most important health care election in the history of the Republic. As of this writing, there are just a few weeks left to make this clear to the American public.

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